Recruiting rural executives

Rural hospitals and health systems often face a leadership Catch-22: They need strong leaders to overcome the well-documented challenges facing rural health care — limited resources and dwindling populations, for example — but struggle to recruit strong leaders because of these challenges.

In our experience, trustees are often the difference makers, depending on their ability to sell their organization to prospective CEOs and executives. In doing so, they must sell their board as being competent and committed and having a vision for the future.

Trustees need to show their passion for the organization above all. “When I feel pride from the board, I know we are starting in a great place,” says Ed Freysinger, who in summer took the reins as chief administrative officer at PeaceHealth Ketchikan (Alaska) Medical Center. Part of Freysinger’s due diligence before taking the position was a thorough review of how well the board was aligned with the organization’s values, its knowledge of the health care climate and its willingness to partner with the new CAO.

Gerald R. Cayer, who signed on in summer as CEO at Lewis County General Hospital in Lowville, N.Y., also took stock of the board. “I was looking for enthusiasm and engagement,” he says. “As the recruitment process continued, I was evaluating ‘health care IQ,’ the presence of safety and quality language in our discussions, the willingness to govern versus micromanage, and personality compatibility,” he says. Ultimately, he says, “I saw a board that was committed to the organization and the communities served.”

Four areas of focus

How can boards of rural systems make sure that they position themselves and their organizations appropriately to recruit strong CEOs and other leaders? For this article, we asked recently hired rural CEOs and several trustees about how they experienced the recruitment process. In considering their input, we believe that four strategies underpin a rural organization’s ability to recruit top-notch executives.

Connect with candidates on mission, vision and values. CEOs and executive candidates will have visited your website and will know your mission, vision and values. What they will investigate is how these statements play out in real life. In terms of mission: Who and what are you as a rural organization? How do you compare and contrast with other rural facilities? For vision: Where are you headed as a rural health care system? For values: What are the standards and criteria by which you make clinical and business decisions?

“We do not want the executive to maintain our status,” says Curtis Lund, board chair at Kalispell (Mont.) Regional Healthcare. In their meetings with candidates, Lund and his colleagues emphasize their mission and focus on future growth and opportunities.

“I wanted to work for an organization that was looking to move forward,” says Thomas J. Kooiman, who joined Minnesota’s Granite Falls Health in 2015 as CEO. Kooiman made sure that the board was thinking along the same lines.

Especially vital, says Freysinger, is showing how mission, vision and values influence executive selection, development and retention, and accelerate clinical, financial and operational performance. For example, how do decisions driven by mission, vision and values allow your organization to expand services, improve outcomes, manage costs or reduce readmissions?

As you discuss these issues, engage candidates in a dialogue about how they addressed mission, vision and values in their most recent position. Also ask how your organization’s statements mesh with candidates’ concepts of personal and professional success. Boards can help candidates sort through a pivotal question: Where are you headed as a person and a professional?

As you speak about values, promote the benefits of rural health care and living and working in a small, rural community. But avoid the tendency to sell yourself short or compare your position with opportunities available in large, urban health care systems.

“Professionals in rural health care are blessed to live and experience the vocation of health care in an environment where community really matters and exists,” says Cayer. “It must be celebrated. Embrace the opportunities and possibilities because they are rural.”

Rural health care also allows executives to make a difference and identify impact. “You can expand your career horizons by working in a rural environment because you have an enhanced opportunity to influence the health care of a community in a positive way,” says Paul Beaupre, M.D., CEO of St. John’s Medical Center in Jackson, Wyo., since 2016.

“We emphasized the quality and compassion of the hospital staff, the strong endorsement of St. John’s by the Jackson community, and the financial strength of the hospital,” says Cynthia Hogan, a retired pharmaceutical executive and board member who helped to recruit Beaupre. “Of course, the beauty of the national parks surrounding Jackson speak for themselves.”

Promote your medical staff, including its role in CEO and C-suite success. We see executive candidates asking the following questions more  often: What about the doctors? The nurses? Are they engaged? The degree to which candidates scrutinize an organization’s clinicians is beyond what it was even five years ago.

Board members must appreciate this and educate themselves on their medical staff. As you skim internal documents, external reviews and media coverage, look for examples of medical staff excellence and performance that you can share with candidates. Evidence may surface in facility rankings from entities like U.S. News & World Report, HCAHPS scores, awards from the National Rural Health Association and the American Hospital Association, or kudos for individual physicians, nurses, groups and specialties. Be prepared to tell the story behind the awards, including the underlying need or opportunity, specific contribution, results and lessons learned.

Consider using survey or anecdotal data to articulate physician satisfaction with factors like quality of nursing staff, inpatient testing, service excellence, clinical information systems, and shared insight into strategic planning, culture and change management. Just as important is demonstrating physician commitment to quality, access, equity and cost management through hot-button issues vital to clinical, operational and financial performance. For example, how have physicians participated in value-based care, population health, patient/consumer experience and engagement, technology selection and implementation, resource allocation, or innovation?

“The medical staff's commitment to quality and engagement came through in multiple interviews,” Cayer says of his CEO interviews at Lewis County General Hospital. “I was also able to evaluate and verify what I heard from clinical leaders by reviewing publicly reported data and recent internal quality documents presented to the board.”

“Almost every candidate seeks an opportunity where the medical staff is committed to improve quality and remains focused on the patient/consumer experience,” adds Beaupre, of St. John’s Medical Center. “Executives want to see a medical staff mobilized in a drive toward quality, compassionate care.”

While it is important to be candid about previous conflicts between medical staff and the C-suite, turn the conversation toward the positive dimensions of physician experience. Discuss how your organization addresses physician frustration via appreciation, statements of accountability, continuing education, compensation, next-generation systems and equipment, reasonable work schedules, or fun in the workplace.

Sharing your medical staff’s strengths and contributions is an extended, two-way conversation. Ask candidates for evidence of how they engaged and collaborated with medical staff in previous positions. But realize that candidates may also have demands in this regard. They could ask to review board minutes and participate in interviews with clinical and staff leaders, which should be considered a good sign.

Make sure the board is at its best. As you interact with candidates, be prepared to discuss board accomplishments. Freysinger advises boards to explore these factors with candidates: mission, vision and values; organizational legacy (i.e., how traditions support today’s decision-making); the health care field past, present and future; and how the board will support the executive in the early stages of employment.

Remember that an executive search is an extended process, not a one-time occurrence. Organizations typically invite board members to a series of candidate interviews and discussions, which sometimes include tours and dinners with spouses. As you interact with a candidate, present success stories of collaboration, innovation and transformation, including how you challenged other board members and the CEO via questioning, visioning and strategic thinking.

Especially vital to the interaction is sharing your understanding of the differences between governance and micromanagement. Boards “must trust that talent knows how to run a rural health care organization and that board members must govern, not manage,” says Beaupre.

The key is “open and transparent communication between the board and management with a goal of advancing and evolving the organization’s mission,” says Pamela Robertson, who recently signed on as CEO at Kalispell Regional Healthcare. Robertson believes that board members’ commitment to quality, safety and engagement is a must to the organization’s long-term success. 

Reject a blue-sky approach to board candidate conversations. Board members need to share what’s right and wrong with an organization and community and prepare for tough questions: Does the board want to maintain the status quo or evolve the organization into something different? What happened to the last CEO? Why have so many people left this area? What do you do here for fun?

Show candidates how you will support their transition. Reveal how you plan to support the new executive once a hiring decision is made. Candidates need to know that the organization will back their needs for financial resources and staff assistance once they arrive. But they also need to understand the process and timetable that underlie family relocation and onboarding into a new organization and community.

“Candidates want evidence of how board members will assist a new leader in integrating into the local area,” says Freysinger. “Board members need a road map for how they will provide guidance and mentoring on the culture of the organization and community.”

Candidates are also eager to know how the organization will support professional and career development through assessment, coaching and education delivered via conferences, seminars, workshops and online learning. They want access to information systems that monitor clinical and business performance, and they want mobile, tablet and laptop devices that ensure connectivity with colleagues and partners.

C-suite executive candidates seek competitive compensation, including a base salary, short- and long-term incentives, benefits, perquisites and severance. While some rural organizations may offer reduced compensation due to a lower cost of living, candidates typically understand compensation ranges for positions in certain regions. An executive search firm can help rural systems by anchoring compensation negotiations in the realities of the market.

Closing the deal

Ultimately, the board’s role in CEO and executive recruitment comes down to a few simple things, especially regarding mission and values and the quality and commitment of clinical staff. From the board’s perspective, ask yourself a few critical questions as you look to recruit a new CEO or other top executive. Does our enthusiasm show? Are we committed to supporting and engaging with executives without getting in their way?

And, finally, don’t sell short the opportunity for health care executives to find meaning and purpose. “We have the opportunity to make a difference,” says Cayer. “How cool is that!”

Beth Nelson ( is a principal in Witt/Kieffer’s health care practice and is based in Oak Brook, Ill. James King ( is a senior partner and chief quality officer with the firm and is based in Shakopee, Minn.